Policy gaps in access to single-pill antihypertensive combinations in Sub-Saharan Africa

Background Hypertension remains a leading cardiovascular risk factor in Sub-Saharan Africa (SSA), where blood pressure control rates are among the lowest worldwide. Single-pill combinations (SPCs) are recommended by the World Health Organization and major hypertension guidelines to improve adherence, blood pressure control, and cardiovascular outcomes. However, access to SPCs in SSA largely depends on national policy decisions reflected in Essential Medicines Lists (EMLs), clinical guidelines, and National Health Policy (NHP) documents. Purpose To systematically assess the inclusion, positioning, and policy coherence of antihypertensive SPCs across national EMLs, hypertension clinical guidelines, and NHP documents in SSA, and to explore regional variation in adoption patterns. Methods The most recent national EMLs, hypertension-related clinical guidelines, and NHP documents were retrieved from official governmental repositories, international databases, and regional health agency platforms. A descriptive and comparative policy analysis was conducted across countries and SSA subregions. Findings were interpreted within the World Health Organization Health System “Leadership and Governance” building block framework, with emphasis on alignment between essential medicine selection and clinical recommendations. Results All countries had an official EML; however, only 21 (42.9%) included at least one antihypertensive SPC. Adoption was more frequent in Eastern and Southern Africa and markedly limited in Central Africa. Countries with EML updates after 2019 were more likely to include SPCs, coinciding with their addition to the WHO Model List of Essential Medicines. National hypertension guidelines were available for only 15 countries; of these, four mentioned SPCs, and only Kenya provided explicit, practice-oriented recommendations for their use. Cross-document analysis revealed substantial policy misalignment: several countries listed SPCs in EMLs without recommending them in guidelines, while others recommended SPC-based therapy without formal EML inclusion. NHP documents rarely addressed SPC implementation pathways, procurement strategies, or financing mechanisms. Conclusions The integration of antihypertensive SPCs into national policy frameworks across SSA remains incomplete, heterogeneous, and frequently misaligned. These governance gaps may constrain access to evidence-based therapies and limit progress toward improved hypertension control and cardiovascular risk reduction. Strengthening policy coherence across essential medicines selection, clinical guidance, and implementation planning will be critical to expanding equitable access to SPCs and advancing cardiovascular health in the region.